Child clinical/pediatric neuropsychology: some recent advances

Neurocognitive and psychosocial profiles of children with Turner syndrome

PURPOSE

Patients with Turner syndrome (TS) have distinct neurocognitive and psychosocial characteristics. However, few clinical studies have reported neuropsychological findings in Korean patients. This study investigated the neurocognitive and psychosocial profiles of Korean children with TS.

METHODS

This retrospective cross-sectional study analyzed 20 pediatric patients (<18 years) with TS at the Department of Pediatric Endocrinology at Yonsei University Severance Children's Hospital in South Korea from January 2016 to March 2019. We selected 20 age- and sex-matched controls from among those who visited the endocrinology clinic and were confirmed to have no clinical abnormalities. All participants underwent several neuropsychological tests.

RESULTS

In the Korean Wechsler Intelligence Scale for Children-IV test, the Full-Scale Intelligence Quotient of the TS group was within the normal range. The Perceptual Reasoning Index, Working Memory Index, and Processing Speed Index scores were significantly lower in the TS group than in the control group. In contrast, the Verbal Comprehension Index did not differ significantly between the groups. The Comprehensive Attention Test results showed that the TS group displayed borderline visual selective attention. The social quotient score was significantly lower in the TS group than in the control group.

CONCLUSION

Pediatric patients with TS in Korea displayed distinct neurocognitive and psychosocial characteristics. Patients in the TS group maintained their verbal function, but their attention, visuospatial function, and social competence were low. Our findings will contribute to the development of education programs for patients with TS to improve their neurocognitive and psychosocial functioning.

Are Young Adult Survivors of Pediatric Cancer Being Overlooked? Cognitive Testing Results and Referrals in Child, Adolescent, and Young Adult Survivors

Treatment gaps in meeting the neuropsychological needs of young adult (YA) cancer survivors can be attributed to several clinical and systemic reasons. Access to neurocognitive care can be increased through the effective integration of neuropsychological monitoring and intervention in survivorship care. In this brief report, we aim to compare the efficacy of a brief neuropsychological screener (DIVERGT) in meeting the assessment and referral needs of pediatric and YA cancer survivors (n = 40) as part of a wellness and survivorship clinic. Participants (n = 40) were patients who presented to a pediatric oncology survivorship clinic over the span of 15 months.

Effects of the individual three-dimensional printed craniofacial bones with a quick response code on the skull spatial knowledge of undergraduate medical students

Understanding the three-dimensional (3D) structure of the human skull is imperative for medical courses. However, medical students are overwhelmed by the spatial complexity of the skull. Separated polyvinyl chloride (PVC) bone models have advantages as learning tools, but they are fragile and expensive. This study aimed to reconstruct 3D-printed skull bone models (3D-PSBs) using polylactic acid (PLA) with anatomical characteristics for spatial recognition of the skull. Student responses to 3D-PSB application were investigated through a questionnaire and tests to understand the requirement of these models as a learning tool. The students were randomly divided into 3D-PSB (n = 63) and skull (n = 67) groups to analyze pre- and post-test scores. Their knowledge was improved, with the gain scores of the 3D-PSB group (50.0 ± 3.0) higher than that of the skull group (37.3 ± 5.2). Most students agreed that using 3D-PSBs with quick response codes could improve immediate feedback on teaching (88%; 4.41 ± 0.75), while 85.9% of the students agreed that individual 3D-PSBs clarified the structures hidden within the skull (4.41 ± 0.75). The ball drop test revealed that the mechanical strength of the cement/PLA model was significantly greater than that of the cement or PLA model. The prices of the PVC, cement, and cement/PLA models were 234, 1.9, and 10 times higher than that of the 3D-PSB model, respectively. These findings imply that low-cost 3D-PSB models could revolutionize skull anatomical education by incorporating digital technologies like the QR system into the anatomical teaching repertoire.

Neurocognitive outcomes in pediatric brain tumors after treatment with proton versus photon radiation: a systematic review and meta-analysis

BACKGROUND

Advances in cancer treatments, particularly the development of radiation therapy, have led to improvements in survival outcomes in children with brain tumors. However, radiation therapy is associated with significant long-term neurocognitive morbidity. The present systematic review and meta-analysis aimed to compare the neurocognitive outcomes of children and adolescents with brain tumors treated with photon radiation (XRT) or proton therapy (PBRT).

METHODS

A systematic search was conducted (PubMed, Embase, Cochrane, and Web of Science from inception until 02/01/2022) for studies comparing the neurocognitive outcomes of children and adolescents with brain tumors treated with XRT vs. PBRT. The pooled mean differences (expressed as Z scores) were calculated using a random effects method for those endpoints analyzed by a minimum of three studies.

RESULTS

Totally 10 studies (n = 630 patients, average age range: 1-20 years) met the inclusion criteria. Patients who had received PBRT achieved significantly higher scores (difference in Z scores ranging from 0.29-0.75, all P < 0.05 and significant in sensitivity analyses) after treatment than those who had received XRT for most analyzed neurocognitive outcomes (i.e., intelligence quotient, verbal comprehension and perceptual reasoning indices, visual motor integration, and verbal memory). No robust significant differences (P > 0.05 in main analyses or sensitivity analyses) were found for nonverbal memory, verbal working memory and working memory index, processing speed index, or focused attention.

CONCLUSIONS

Pediatric brain tumor patients who receive PBRT achieve significantly higher scores on most neurocognitive outcomes than those who receive XRT. Larger studies with long-term follow-ups are needed to confirm these results.

Visual-Motor Integration Deficits in 3q29 Deletion Syndrome

3q29 deletion syndrome (3q29del) is associated with neuropsychiatric and neurodevelopmental phenotypes. We previously reported that graphomotor weakness is present in up to 78% of individuals with 3q29del. We have now explored nuances of the graphomotor phenotype and its association with other comorbidities in this population. Participants were recruited from the online 3q29 registry (3q29deletion.org) for two days of deep phenotyping. 32 individuals with 3q29del (62.5% male) were evaluated with the Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI) to assess visual-motor integration. Participants were also evaluated with measures of cognitive ability, executive function, adaptive behavior, and school function. Males with 3q29del performed significantly worse than females on the VMI and Motor Coordination subtest. VMI performance was significantly associated with ADHD diagnosis and cognitive ability. Compared to published data from individuals with 22q11.2 deletion syndrome, individuals with 3q29del showed significantly more impairment. The 3q29 deletion is associated with substantial deficits in visual-motor integration, Visual Perception, and Motor Coordination. Our data suggests that 3q29del may qualify as a nonverbal learning disability. Future studies should assess whether individuals with 3q29del would benefit from early interventions, including occupational therapy.

A Systematic Review of Host Genomic Variation and Neuropsychological Outcomes for Pediatric Cancer Survivors

Pediatric survivors of brain tumors and acute lymphoblastic leukemia (ALL) are at risk for long-term deficits in their neuropsychological functioning. Researchers have begun examining associations between germline single nucleotide polymorphisms (SNPs), which interact with cancer treatment, and neuropsychological outcomes. This review synthesizes the impact of treatment-related toxicity from germline SNPs by neuropsychological domain (i.e., working memory, processing speed, psychological functioning) in pediatric survivors. By focusing on specific neuropsychological domains, this review will examine outcome measurement and critique methodology. Fourteen studies were identified and included in this review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). All studies were published in peer-reviewed journals in English by November 24^th, 2021. Reviewed studies were not of sufficient quality for a meta-analysis due to varying measurement strategies, gaps in reported descriptive variables, and low power. All neuropsychological domains evaluated in this review had associations with SNPs, except fine motor and visual integration abilities. Only five SNPs had consistent neuropsychological findings in more than one study or cohort. Future research and replication studies should use validated measures of discrete skills that are central to empirically validated models of survivors' long-term outcomes (i.e., attention, working memory, processing speed). Researchers should examine SNPs across pathophysiological pathways to investigate additive genetic risk in pediatric cancer survivors. Two SNPs were identified that confer resiliency in neuropsychological functioning, and future work should investigate resiliency genotypes and their underlying biological mechanisms.

Systematic Review: Nonverbal Learning Disability

OBJECTIVE

To summarize the current state of the research literature on nonverbal learning disability (NVLD), including criteria used to define NVLD in research contexts and the quality of the extant research; and to determine what research can tell us about ways in which NVLD is distinct from DSM neurodevelopmental disorders and typical development.

METHOD

A systematic search of 7 databases was conducted to identify research on NVLD published through February 2019. Criteria used to define NVLD were extracted from identified studies and sorted by category. Each study was assessed for risk of bias and rated "good," "fair," or "poor;" findings from studies rated good or fair were summarized.

RESULTS

A total of 61 articles (63 studies) met inclusion criteria. There was great heterogeneity in the criteria used to define NVLD. Deficits in visuospatial ability/intelligence was the most common criterion used, followed by discrepancy between verbal and nonverbal intelligence (VIQ>PIQ split of 10 or greater). All studies were cross-sectional and most included small, poorly described samples. Most studies focused on children and young adolescents. Eight studies were rated as good, 42 as fair, and 13 as poor. Review of results from the 50 good or fair studies suggest that there is sufficient evidence that youths with NVLD (as defined by significant deficits in visuospatial abilities) can be clearly differentiated from their typically developing peers, those with verbal learning disorders, and from other clinical groups (eg, individuals with high functioning autism).

CONCLUSION

A standard set of criteria for determining an NVLD diagnosis would greatly improve research studies and the possibility of inclusion in the DSM and the International Classification of Diseases.

Considering learning disabilities and attention-deficit hyperactivity disorder when assessing for neurodegenerative disease

Purpose of review

When evaluating an older adult for a possible neurodegenerative disease, the role of premorbid specific learning disabilities or attention-deficit hyperactivity disorder (ADHD) should be considered. These neurodevelopmental conditions can manifest as lifelong weaknesses and variability in cognitive functions that complicate assessment of cognitive decline. There is also accumulating evidence that certain neurodevelopmental disorders may entail greater risk for specific neurodegenerative disorders.

Recent findings

We describe clinical cases where diagnosis of neurodegenerative disease was influenced by preexisting neurodevelopmental disorders. We also present a questionnaire to assist with screening for premorbid learning disabilities and ADHD in older adults.

Summary

This article offers clinical guidance for practicing neurologists in the identification and assessment of neurodevelopmental disorders in older adult patients, which informs management and treatment. Consideration of lifetime functioning has become increasingly important with research linking neurodevelopmental disabilities to increased risk of specific neurodegenerative diseases.

Motor Competence in Children With and Without Ambliopia

The purpose of this study was to assess the motor competence of children with and without amblyopia. Study participants were 165 primary school children, aged 6-9 years, divided into three groups based on their visual acuity with the Snellen chart: (a) non-amblyopia, (b) corrected amblyopia, and (c) non-corrected amblyopia. We assessed the children's motor competence with the Motor Competence Assessment battery (MCA) and their physical activity with the Physical Activity Questionnaire for Older Children (PAQ-C). The non-amblyopia group presented significantly better motor competence on the MCA than either the corrected amblyopia group or the non-corrected amblyopia group; there were no statistically significant motor differences between the two amblyopia subgroups. Amblyopia versus non-amblyopia differences on the MCA were mainly in stability and locomotor components, involving dynamic balance and the change of spatial position and direction of movement, but not in the manipulative component (ball throwing velocity and ball kicking velocity). Predictably, from within an integrated visual motor perspective of child development, our findings suggest that intact vision played an important role in children's motor competence. The development of fundamental motor skills, especially of stability and locomotor skills, may be affected by poor visual processing in that participants with uncorrected amblyopia showed poor movement accuracy, uncoordinated movement, and impaired balance.

Improved neuropsychological outcomes following proton therapy relative to X-ray therapy for pediatric brain tumor patients

BACKGROUND

Survivors of pediatric brain tumors are at risk for impaired development in multiple neuropsychological domains. The purpose of this study was to compare neuropsychological outcomes of pediatric brain tumor patients who underwent X-ray radiotherapy (XRT) versus proton radiotherapy (PRT).

METHODS

Pediatric patients who underwent either XRT or PRT and received posttreatment age-appropriate neuropsychological evaluation-including measures of intelligence (IQ), attention, memory, visuographic skills, academic skills, and parent-reported adaptive functioning-were identified. Multivariate analyses were performed to assess differences in neuropsychological outcomes and included tests for interaction between treatment cohort and follow-up time.

RESULTS

Between 1998 and 2017, 125 patients with tumors located in the supratentorial (17.6%), midline (28.8%), or posterior fossa (53.6%) compartments received radiation and had posttreatment neuropsychological evaluation. Median age at treatment was 7.4 years. The PRT patient cohort had higher estimated SES and shorter median time from radiotherapy completion to last neuropsychological evaluation (6.7 vs 2.6 y, P < 0.001). On multivariable analysis, PRT was associated with higher full-scale IQ (β = 10.6, P = 0.048) and processing speed (β = 14.4, P = 0.007) relative to XRT, with trend toward higher verbal IQ (β = 9.9, P = 0.06) and general adaptive functioning (β = 11.4, P = 0.07). Planned sensitivity analyses truncating follow-up interval in the XRT cohort re-demonstrated higher verbal IQ (P = 0.01) and IQ (P = 0.04) following PRT, with trend toward improved processing speed (P = 0.09).

CONCLUSIONS

PRT is associated with favorable outcomes for intelligence and processing speed. Combined with other strategies for treatment de-intensification, PRT may further reduce neuropsychological morbidity of brain tumor treatment.

Motor functioning and associated cognitive outcomes in pediatric survivors of acute lymphoblastic leukemia

Pediatric acute lymphoblastic leukemia survivors are at risk for developing neurocognitive late effects following intensive medical treatment. Motor impairments have been highlighted as a common neurocognitive late effect, including fine-, gross-, and visual-motor skills. The severity of these motor deficits is variable in the existing literature, warranting additional investigations with more homogenous samples. In addition, there is an even greater paucity regarding the interrelations between motor deficits and the impact motor challenges may have on other domains of functioning, such as academics. Therefore, the present study aimed to characterize motor functioning in children who were treated for acute lymphoblastic leukemia with chemotherapy (n = 13) in comparison to healthy controls (n = 13). Additionally, this study investigated the relationship between primary (e.g., visual-spatial, fine-motor), secondary (e.g., visual-motor), and tertiary (e.g., academics) skills. The results revealed that oncology survivors had significantly lower fine- and gross-motor skills compared to healthy controls. No significant differences were observed between the groups on visual-perception and visual-motor tasks. Fine-motor functioning was significantly associated with visual-motor functioning in ALL survivors. Motor skills were not related to academic outcomes. The present findings provide evidence for motor impairments in pediatric ALL survivors, along with initial findings highlighting the cascading effect of primary motor impairments on other cognitive domains. This research sheds light on the need for clinical screening and intervention of motor skills in the survivorship population. Future research is warranted to examine the effect of motor deficits on cognitive and psychosocial functioning in pediatric oncology.

Recognition and management of adults with Turner syndrome: From the transition of adolescence through the senior years

Turner syndrome is recognized now as a syndrome familiar not only to pediatricians and pediatric specialists, medical geneticists, adult endocrinologists, and cardiologists, but also increasingly to primary care providers, internal medicine specialists, obstetricians, and reproductive medicine specialists. In addition, the care of women with Turner syndrome may involve social services, and various educational and neuropsychologic therapies. This article focuses on the recognition and management of Turner syndrome from adolescents in transition, through adulthood, and into another transition as older women. It can be viewed as an interpretation of recent international guidelines, complementary to those recommendations, and in some instances, an update. An attempt was made to provide an international perspective. Finally, the women and families who live with Turner syndrome and who inspired several sections, are themselves part of the broad readership that may benefit from this review.

A research framework to isolate visuospatial from childhood motor coordination phenotypes

Clinicians acknowledge the presence of developmental cognitive phenotypes mainly characterized by a specific visuospatial impairment in presence of intact verbal functioning (usually referred as Nonverbal Learning Disability: NLD) since many decades, without providing sufficient empirical evidence supporting their nosological validity and inclusion in current diagnostic manuals. This contribution suggests that the goal of including NLD in future diagnostic manuals could be achieved only be the demonstration of the validity of this hypothesized clinical category. Considering the blind spot of empirical literature represented by the differential diagnosis of NLD, this issue should the primary focus of empirical research supported by a renewed interest on NLD. Both neurophysiological and clinical evidence suggest that the differential diagnosis and the related empirical comparison should be primarily settled with Developmental Coordination Disorder, looking for the possible identification of children presenting a visuospatial impairment in absence of severe motor coordination impairment. In conclusion, further studies are needed to support the validity of NLD as valid diagnostic category to be included in future revisions of diagnostic manuals.

Take away body parts! An investigation into the use of 3D-printed anatomical models in undergraduate anatomy education

Understanding the three-dimensional (3D) nature of the human form is imperative for effective medical practice and the emergence of 3D printing creates numerous opportunities to enhance aspects of medical and healthcare training. A recently deceased, un-embalmed donor was scanned through high-resolution computed tomography. The scan data underwent segmentation and post-processing and a range of 3D-printed anatomical models were produced. A four-stage mixed-methods study was conducted to evaluate the educational value of the models in a medical program. (1) A quantitative pre/post-test to assess change in learner knowledge following 3D-printed model usage in a small group tutorial; (2) student focus group (3) a qualitative student questionnaire regarding personal student model usage (4) teaching faculty evaluation. The use of 3D-printed models in small-group anatomy teaching session resulted in a significant increase in knowledge (P = 0.0001) when compared to didactic 2D-image based teaching methods. Student focus groups yielded six key themes regarding the use of 3D-printed anatomical models: model properties, teaching integration, resource integration, assessment, clinical imaging, and pathology and anatomical variation. Questionnaires detailed how students used the models in the home environment and integrated them with anatomical learning resources such as textbooks and anatomy lectures. In conclusion, 3D-printed anatomical models can be successfully produced from the CT data set of a recently deceased donor. These models can be used in anatomy education as a teaching tool in their own right, as well as a method for augmenting the curriculum and complementing established learning modalities, such as dissection-based teaching. Anat Sci Educ 11: 44-53. © 2017 American Association of Anatomists.

Local and global processing in block design tasks in children with dyslexia or nonverbal learning disability

Visuo-constructive and perceptual abilities have been poorly investigated in children with learning disabilities. The present study focused on local or global visuospatial processing in children with nonverbal learning disability (NLD) and dyslexia compared with typically-developing (TD) controls. Participants were presented with a modified block design task (BDT), in both a typical visuo-constructive version that involves reconstructing figures from blocks, and a perceptual version in which respondents must rapidly match unfragmented figures with a corresponding fragmented target figure. The figures used in the tasks were devised by manipulating two variables: the perceptual cohesiveness and the task uncertainty, stimulating global or local processes. Our results confirmed that children with NLD had more problems with the visuo-constructive version of the task, whereas those with dyslexia showed only a slight difficulty with the visuo-constructive version, but were in greater difficulty with the perceptual version, especially in terms of response times. These findings are interpreted in relation to the slower visual processing speed of children with dyslexia, and to the visuo-constructive problems and difficulty in using flexibly-experienced global vs local processes of children with NLD. The clinical and educational implications of these findings are discussed.

National Institutes of Health Hematopoietic Cell Transplantation Late Effects Initiative: The Patient-Centered Outcomes Working Group Report

In 2015, the National Institutes of Health convened six working groups to address the research needs and best practices for late effects of hematopoietic stem cell transplantation survivors. The Patient-Centered Outcomes Working Group, charged with summarizing the HRQOL evidence base, used a scoping review approach to efficiently survey the large body of literature in adult and pediatric HCT survivors over 1 year after transplantation. The goals of this paper are to (1) summarize the current literature describing patient-centered outcomes in survivors, including the various dimensions of health-related quality of life affected by HCT, and describe interventions tested to improve these outcomes; (2) highlight areas with sufficient evidence allowing for integration into standard practice; (3) address methodological issues that restrict progress in this field; (4) identify major gaps to guide future research; and (5) specify priority research recommendations. Patient-centered outcomes were summarized within physical, psychological, social, and environmental domains, as well as for adherence to treatment, and health behaviors. Interventions to improve outcomes were evaluated for evidence of efficacy, although few interventions have been tested in long-term HCT survivors. Methodologic issues defined included lack of consistency in the selection of patient-centered outcome measures, along with the absence of a standard for timing, frequency, and mode of administration. Recommendations for HCT survivorship care included integration of annual screening of patient-centered outcomes, use of evidence-based practice guidelines, and provision of treatment summaries and survivorship care plans after HCT. Three priority research recommendations included the following: (1) design and test risk-targeted interventions with dose-intensity modulation matching the needs of HCT survivors with priority domains, including sexual dysfunction, fatigue, sleep disruption, nonadherence to medications and recommended health care, health behaviors including physical inactivity and healthy eating, and psychological dysfunction, with particular consideration of novel technologies to reach HCT survivors distant from their transplantation centers; (2) design a consensus-based methodologic framework for outcomes evaluation; and (3) evaluate and compare existing practices for integrating patient-centered outcome screening and interventions across HCT survivorship programs.

Asperger syndrome and nonverbal learning difficulties in adult males: self- and parent-reported autism, attention and executive problems

A specific overlap between Asperger syndrome (AS) and nonverbal learning difficulties (NLD) has been proposed, based on the observation that, as a group, people with AS tend to have significantly higher verbal IQ (VIQ) than performance IQ (PIQ), one of the core features of NLD. The primary aim was to assess the longer term outcome of NLD--broken down into persistent and transient forms. The present study of 68 individuals was performed in the context of a larger prospective longitudinal study to late adolescence/early adult life of 100 boys with AS. Using self- and parent-report measures, we studied the longer term outcome of the NLD (defined as VIQ > PIQ by 15 points) as regards social communication, repetitive behaviour, attention, and executive function (EF) was studied. Three subgroups were identified: (1) Persistent NLD (P-NLD), (2) Childhood "only" NLD (CO-NLD) and (3) Never NLD (NO-NLD). The P-NLD group had the worst outcome overall. The CO-NLD group had better reported EF scores than the two other AS subgroups. There were no differences between the subgroups regarding social communication, repetitive behaviour, or attentional skills. Low PIQ increased the risk of ADHD symptoms. In the context of AS in males, P-NLD carries a relatively poor outcome, particularly with regard to self-reported EF. However, CO-NLD appears to entail a significantly better outcome. The results underscore the importance of analysing the cognitive profile both at diagnosis and after several years, so as to be able to formulate a realistic prognosis.

Observed differences in social behaviors exhibited in peer interactions between youth with spina bifida and their peers: neuropsychological correlates

OBJECTIVE

To identify differences in social behaviors in observed peer interactions between children with spina bifida (SB) and peers, and to examine neuropsychological correlates of these differences.

METHOD

A total of 100 youth (aged 8-15 years) with SB and peers participated in video-recorded interaction tasks, which were coded for interaction style, affect, and collaboration. Children with SB also completed a neuropsychological test battery.

RESULTS

Children with SB demonstrated less adaptive social behaviors in peer interactions, particularly within the interaction style domain. Observational items found to be different between children with SB and their peers were best predicted by social language and attention abilities.

CONCLUSIONS

Children with SB exhibit a less adaptive interaction style and lower levels of social dominance but are comparable with typically developing peers on other social behaviors. The observed group differences may have a neuropsychological basis.

Learning of writing letter-like sequences in children with physical and multiple disabilities

This study compared implicit and explicit learning instructions in hand writing. Implicit learning is the ability to acquire a new skill without a corresponding increase in knowledge about the skill. In contrast, explicit learning uses declarative knowledge to build up a set of performance rules that guide motor performance or skills. Explicit learning is dependent on working memory, implicit learning is not. Therefore, implicit learning was expected to be easier than explicit learning in children in special education, given their expected compromised working memory. Two groups of children (5-12 years) participated, children in special education with physical or multiple disabilities (study group, n=22), and typically developing controls (n=32). Children learned to write letter-like patterns on a digitizer by tracking a moving target (implicitly) and verbal instruction (explicitly). We further tested visual working memory, visual-motor integration, and gross manual dexterity. Learning curves were similar for both groups in both conditions; children in the study group did learn both implicitly and explicitly. Motor performance was related to the writing task. In contrast to our hypothesis, visual working memory was not an important factor in the explicit condition. These results shed new light on the conceptual difference between implicit and explicit learning, and the role of working memory therein.

Long-term outcome in children with low grade tectal tumours and obstructive hydrocephalus

BACKGROUND

Neuropsychological deficits after treatment of paediatric brain tumour are well known, but not the role of hydrocephalus in these deficits.

AIMS

To study long-term neurological, cognitive, and behavioural deficits in children with a low grade tectal tumour and acquired obstructive hydrocephalus.

METHODS

In a consecutive series of 12 children with low-grade tectal tumour diagnosed in our hospital between 1994 and 2008, neurologic, neuropsychological, and radiologic data were prospectively collected. Intelligence, memory, attention, language, visual-spatial, and executive functions were assessed. Median follow-up was 2 years and 9 months.

RESULTS

At follow-up, most frequent neurologic disability was fatigue in children with a low-grade tectal tumour. They scored lower on sustained attention, long-term memory and had more behavioural problems. Factor influencing cognition was persisting severe hydrocephalus at time of assessment. The cognitive problems resulted in 60% of children needing assistances of special services at school.

CONCLUSIONS

At long-term, children with a low-grade tectal tumour display invalidating neuropsychological impairments resulting in educational problems. Adequate treatment of hydrocephalus may result in better cognitive functioning. Our findings suggest that part of the symptoms of the cerebellar cognitive affective syndrome may not have resulted from a cerebellar lesion itself but rather from a cerebral dysfunction or compression of supratentorial structures in the cerebello-cortical circuitry due to the obstructive hydrocephalus.

Adult expression of a 3q13.31 microdeletion

Background

The emerging 3q13.31 microdeletion syndrome appears to encompass diverse neurodevelopmental conditions. However, the 3q13.31 deletion is rare and few adult cases have yet been reported. We examined a cohort with schizophrenia (n = 459) and adult control subjects (n = 26,826) using high-resolution microarray technology for deletions and duplications at the 3q13.31 locus.

Results

We report on the extended adult phenotype associated with a 3q13.31 microdeletion in a 41-year-old male proband with schizophrenia and a nonverbal learning disability. He was noted to have a speech impairment, delayed motor skills, and other features consistent with the 3q13.31 microdeletion syndrome. The 2.06 Mb deletion overlapped two microRNAs and seven RefSeq genes, including GAP43, LSAMP, DRD3, and ZBTB20. No overlapping 3q13.31 deletions or duplications were identified in control subjects.

Conclusions

Later-onset conditions like schizophrenia are increasingly associated with rare copy number variations and associated genomic disorders like the 3q13.31 microdeletion syndrome. Detailed phenotype information across the lifespan facilitates genotype-phenotype correlations, accurate genetic counselling, and anticipatory care.

Applicability of the nonverbal learning disability paradigm for children with 22q11.2 deletion syndrome

Chromosome 22qll.2 deletion syndrome (22qllDS) is the most common microdeletion in humans. Nonverbal learning disability (NLD) has been used to describe the strengths and deficits of children with 22q11DS, but the applicability of the label for this population has seldom been systematically evaluated. The goal of the current study was to address how well the NLD diagnosis characterizes children and adolescents with 22q11DS. A total of 74 children and adolescents with 22q11DS were given neurocognitive, socioemotional, and academic assessments to measure aspects of NLD. Of the cohort, 20% met at least 7 of 9 assessed criteria for NLD; 25% showed verbal skills exceeding their nonverbal skills as assessed by an IQ test; and 24% showed the good rote verbal capacity commonly associated with NLD. Hypothesizing that if the entire cohort did not show consistent NLD characteristics, the descriptor might be more accurate for a distinct subgroup, the authors used latent class analysis to divide participants into three subgroups. However, the lines along which the groups broke out were more related to general functioning level than to NLD criteria. All three groups showed a heightened risk for psychiatric illness, highlighting the importance of careful mental health monitoring for all children with 22qllDS.

The perceptual preferences in learning among dental students in clinical subjects

INTRODUCTION

VARK is a questionnaire which was developed by Neil Fleming (www.vark.learn.com), who was a teacher and an educator in New Zealand, with respect to the perceptual preferences in learning. V stands for Visual- the students learn best from pictures, graphs and diagrams. A stand for Aural - the students learn best from spoken words, lectures and discussions. R stands for Reading - the students learn best from reading and writing texts. K stands for Kinesthetic - the students learn best when they move their bodies and manipulate things with their own hands.

AIM

The aim of the recent study was to investigate the learning styles among the dental students in our clinical set up.

METHOD

The VARK-questionnaire contains 13 multiple-choice- questions with four possibilities to select an answer. Each possibility represents one of the four modes of perception. But, one can select more than one answer for each question, which is necessary for the identification of the poly modal modes of perception and learning. This is also a psychometric problem when an attempt is being made to state a measure of the reliability of the questionnaire. The VARK-questionnaire was distributed among 100 students and we received filled forms from only 70 students. This sample size represented a 70% response rate from the students in the class and it was markedly above the level which was required to make conclusions about the student preferences for receiving and processing information. The students spent about 10 minutes in an ordinary lesson to fill in the questionnaire. The students' register numbers and names were used in the study and no blinding was practised. We analyzed their learning styles with their performances in the university exams.

STUDY DESIGN

This was a questionnaire based clinical study.

RESULTS

The responses from the students in our University where classified into the multi-modal (VARK), tri-modal (VRK, VAK, VAR, ARK), bi-modal (VR, VA, VK, RK) and the uni-modal (V, A, R.K) categories. The results showed that the subjects had a higher preference for multimodal learning.

CONCLUSION

With our preliminary data, we conclude that the students in our clinical set up preferred a multimodal and a more of kinesthetic method of learning. To meet their needs, variations in the teaching, learning and the examination must be implemented. If not, the students with a high kinesthetic preference for perception and learning may be at the losing end.

Maple syrup urine disease (MSUD): a case with long-term follow-up after liver transplantation

Maple syrup urine disease (MSUD) is a rare hereditary metabolic condition where the body is unable to breakdown amino acids causing toxic buildup. Acute and long-term management of MSUD involves a restricted diet and regular monitoring of amino acid levels; however, more recently liver transplants have been shown to be successful in treating this condition. Even with successful management of MSUD there is evidence from pediatric cases that shows a distinct pattern of neurocognitive deficits associated with this condition, including impaired nonverbal skills and psychomotor functioning with relatively intact verbal abilities. In the present paper, we report an adult case of MSUD with associated neurocognitive deficits and functional limitations following liver transplantation. Neuroimaging revealed no structural abnormalities, while the results from the neuropsychological evaluation showed impairment in visual-spatial processing, attention, executive functioning, and psychomotor abilities, with relative strengths in verbal skills. The patient also showed reduced adaptive functioning and mild anxiety. This case demonstrates neurocognitive deficiencies within the context of normal magnetic resonance imaging. The possible underlying mechanism of this neuropsychological profile is discussed in relation to other neurodevelopmental models.

Nonverbal learning disability

Nonverbal learning disability (NLD) is described as a subtype of specific learning disability where the source of the disability is a difficulty in processing nonverbal information. The child with NLD presents with problems in visual, spatial, and tactile perception but with strengths in rote verbal skills. Traditionally, these children were recognized by their difficulties in arithmetic which presented a stark contrast with their strengths in spelling and decoding text. They also exhibited a split between their verbal IQ (VIQ) and performance IQ (PIQ) scores with the VIQ being significantly higher than PIQ. Over time, however, diagnostic criteria have evolved and the broadened definition of the NLD syndrome has led many to question the utility and uniqueness of the NLD diagnosis. In addition, shifting diagnostic standards have made research results difficult to replicate. In short, the research to date leaves many unanswered questions about (1) the definition of the NLD syndrome, (2) the pervasiveness of the academic, social and psychopathological difficulties, (3) the source of the NLD syndrome, and (4) the degree to which it overlaps with other conditions. This chapter outlines a brief history of the NLD syndrome, how it is currently conceptualized, and some of the current debate about the unanswered questions above.

Discrepancies between academic achievement and intellectual ability in higher-functioning school-aged children with autism spectrum disorder

Academic achievement patterns and their relationships with intellectual ability, social abilities, and problem behavior are described in a sample of 30 higher-functioning, 9-year-old children with autism spectrum disorder (ASD). Both social abilities and problem behavior have been found to be predictive of academic achievement in typically developing children but this has not been well studied in children with ASD. Participants were tested for academic achievement and intellectual ability at age 9. Problem behaviors were assessed through parent report and social functioning through teacher report at age 6 and 9. Significant discrepancies between children's actual academic achievement and their expected achievement based on their intellectual ability were found in 27 of 30 (90%) children. Both lower than expected and higher than expected achievement was observed. Children with improved social skills at age 6 demonstrated higher levels of academic achievement, specifically word reading, at age 9. No relationship was found between children's level of problem behavior and level of academic achievement. These results suggest that the large majority of higher-functioning children with ASD show discrepancies between actual achievement levels and levels predicted by their intellectual ability. In some cases, children are achieving higher than expected, whereas in others, they are achieving lower than expected. Improved social abilities may contribute to academic achievement. Future studies should further explore factors that can promote strong academic achievement, including studies that examine whether intervention to improve social functioning can support academic achievement in children with ASD.

Mental Representation of Spatial Information in Children with Non-Verbal and Reading Disabilities: Two Case Studies

Non-verbal learning disability (NLD) is a specific difficulty related to the processing of visuo-spatial material. The aim of the present study is to elucidate the profile of NLD as regards ability to process and comprehend spatial descriptions, through the analysis of individual cases. Our study examined one child with NLD (M.N.), plus a second child (G.B.) with reading disability (RD) for comparison. The two children had similar reading comprehension ability. They listened to two spatial descriptions, in both survey (i.e., bird's-eye view) and route (i.e., person's point of view) perspective, plus one non-spatial description. They then answered questions about the descriptions and relocated landmarks from the spatial descriptions on a map. Performance of the child with NLD was poor in spatial descriptions but good in the non-spatial description. In particular, task performance was poorer after survey description learning. Instead, G.B. performed well in both non-spatial and spatial (i.e., survey and route) descriptions. The NLD child was shown to be specifically impaired in ability to mentally represent spatial information in survey perspective.

Neuropsychological differences among children with Asperger syndrome, nonverbal learning disabilities, attention deficit disorder, and controls

Confusion is present as to possible diagnostic differences between Asperger syndrome (AS) and Nonverbal learning disabilities (NLD) and the relation of these disorders to attentional difficulties. Three-hundred and forty-five children participated in this study in 5 groups; NLD, AS, attention deficit hyperactivity disorder (ADHD): Combined type, ADHD: Inattentive type, and controls. The NLD group showed particular difficulty on visual-spatial, visual-motor, and fluid reasoning measures compared to the other groups. There was also a significant verbal-performance IQ split in this group related to difficulty in social functioning. This study extends the findings from previous studies and extends these findings to differences between AS and NLD groups.

Investigating verbal and visual auditory learning after conformal radiation therapy for childhood ependymoma

PURPOSE

The primary objective of this study was to determine whether children with localized ependymoma experience a decline in verbal or visual-auditory learning after conformal radiation therapy (CRT). The secondary objective was to investigate the impact of age and select clinical factors on learning before and after treatment.

METHODS AND MATERIALS

Learning in a sample of 71 patients with localized ependymoma was assessed with the California Verbal Learning Test (CVLT-C) and the Visual-Auditory Learning Test (VAL). Learning measures were administered before CRT, at 6 months, and then yearly for a total of 5 years.

RESULTS

There was no significant decline on measures of verbal or visual-auditory learning after CRT; however, younger age, more surgeries, and cerebrospinal fluid shunting did predict lower scores at baseline. There were significant longitudinal effects (improved learning scores after treatment) among older children on the CVLT-C and children that did not receive pre-CRT chemotherapy on the VAL.

CONCLUSION

There was no evidence of global decline in learning after CRT in children with localized ependymoma. Several important implications from the findings include the following: (1) identification of and differentiation among variables with transient vs. long-term effects on learning, (2) demonstration that children treated with chemotherapy before CRT had greater risk of adverse visual-auditory learning performance, and (3) establishment of baseline and serial assessment as critical in ascertaining necessary sensitivity and specificity for the detection of modest effects.

Associations between performance on the Rey-Osterrieth Complex Figure and regional brain volumes in children with and without velocardiofacial syndrome

Ninety-two children with velocardiofacial syndrome (VCFS), a genetic disorder caused by a microdeletion of chromosome 22q11.2 and an age, race, and gender-ratio comparable sample of 59 control participants were included in the project. Participants received an MRI as well as a comprehensive neuropsychological battery; the primary outcome measure in the current report is the Rey-Osterrieth Complex Figure (ROCF). Children with VCFS performed less well on the ROCF and have lower whole brain volume compared to controls. After controlling for whole brain volume differences, children with VCFS have bilaterally less parietal lobe gray and white matter yet more frontal lobe white matter. Brain-behavior relationships include: (a) for both groups, parietal volumes (both gray and white matter) predicted ROCF Copy Organization performance and frontal volumes (both gray and white matter) predicted ROCF Copy Accuracy performance; (b) for controls, frontal white matter also predicted ROCF Copy Organization performance; (c) ROCF Recall Organization performance was best predicted by frontal gray matter volume only in our controls; ROCF Recall Accuracy performance was best predicted by frontal gray matter volume in both groups; and (d) in children with VCFS, performance on the ROCF-Copy Structural Elements Accuracy scale was predicted by right hemisphere white matter volume. Our hypotheses were also retested using IQ-matched and whole brain volume-matched subsamples. Identical results were obtained in these analyses. Assumptions about the organization of and the localization of the brain structures that subserve specific cognitive functions in the typically developing brain may not apply in the abnormally developing brain.

Neuropsychological functioning in subgroups of children with and without social perception deficits and/or hyperactivity--impulsivity

OBJECTIVE

The purpose of this study is to ascertain whether there are differences among groups of children based on their social perception skills in visual perception and fluid reasoning to assist in more effective intervention planning.

METHOD

A total of 80 children were grouped on the basis of their performance on a social perception measure (Child and Adolescent Social Perception) and the presence or absence of hyperactive-impulsive behaviors. They were administered a battery of tests to determine whether the groups differed in their visual perceptual skills and fluid reasoning abilities.

RESULTS

The groups with poor social perception significantly differed from groups with intact social perception on the Rey-O and Fluid Reasoning but not on the Judgment of Line Orientation or the Developmental Test of Visual Motor Integration.

CONCLUSION

A subgroup of children with ADHD demonstrates poor social perception skills and accompanying deficits in complex visual perception and fluid reasoning.

Is neuropsychology a psychosocial science?

Many early investigators of brain-behavior relationships focused their investigative efforts on the psychiatric implications of brain damage and dysfunction. Descriptions of emotional dyscontrol and other psychosocial difficulties appeared frequently in their writings. Although dimensions of perception, memory, and cognition dominate the current neuropsychological literature, the psychosocial implications of patterns of neuropsychological assets and deficits retain their importance (e.g., in the study of the dementing diseases of adulthood). Our investigations of brain-behavior relationships and their impact on psychosocial functioning have attempted to expand upon and chart a somewhat different (subtypal) course for this area of study. One clearly evident conclusion of these efforts is that neuropsychology is a psychosocial science. Some implications of our findings for research and clinical practice are outlined.

Is there an increased familial prevalence of psychopathology in children with nonverbal learning disorders?

The cognitive and behavioral symptoms of nonverbal learning disabilities (NLD) have been described by previous investigators. Nevertheless, we know far less about the potential genetic contributions that may predispose a child to have NLD. An endophenotype model was investigated in 5 samples of children ages 9 to 15 years: NLD (n = 32); reading disorders (RD; n = 59); participants with a psychiatric diagnosis but without a learning disability (n = 55); typically developing controls (n = 31); and children with velocardiofacial syndrome (VCFS), a chromosomal deletion syndrome that has been proposed as being an exemplar of NLD (VCFS + NLD; n = 20). Based on a family genetic interview, the authors' data suggest that children with NLD, RD, or a psychiatric diagnosis have a higher prevalence rate of attention-deficit/hyperactivity disorder (ADHD) and substance abuse/dependence. Psychiatric controls and children with NLD--but not children with RD-- showed higher prevalence rates of familial bipolar disorder.

Nichtsprachliche Lernstörung: Eine unspezifische oder richtungsweisende Klassifikation?

Die nichtsprachliche Lernstörung stellt eine Subgruppe von Lernstörungen dar, die in Kanada und den USA in der praktischen Arbeit mit Kindern einen wichtigen Platz eingenommen hat. Die nichtsprachliche Lernstörung umfasst verschiedene kognitive Defizite, die sich primär auf visuelle und taktile Schwierigkeiten beziehen, aber auch Beeinträchtigungen in der Flexibilität des Denkens und der Psychomotorik berücksichtigen. Durch die Verwendung dieser Klassifikation ist es möglich, eine Gruppe von lerngestörten Kindern zu beachten, die in den internationalen Klassifikationsrichtlinien keine Entsprechung finden. Die Entwicklung, die Ursachen und die Diagnostik dieser Störung werden vorgestellt und kritisch beleuchtet. Der Nutzen dieser Klassifikation wird hinterfragt und auf der Basis aktueller diagnostischer Anforderungen diskutiert. Vorschläge für die Weiterentwicklung und Anpassung der Klassifikation an deutsche Standards werden vorgenommen.

Socio-communicative deficits in young children with Williams syndrome: performance on the Autism Diagnostic Observation Schedule

In this investigation, the socio-communicative skills of 29 children with Williams syndrome aged 2 (1/2) to 5 (1/2) years were examined using the Autism Diagnostic Observation Schedule (ADOS) Module 1. Most of the participants showed socio-communicative difficulties. Approximately half of the participants were classified by the ADOS algorithm as "autism spectrum." Three participants were classified "autism." Difficulties with pointing, gestures, giving, showing, and eye contact were present for more than half of the participants, with many also showing difficulties with initiation and response to joint attention and with integration of gaze with other behaviors. Expressive and receptive language abilities of the children with Williams syndrome classified "autism spectrum" were weaker than for children classified nonspectrum, but expressive and receptive language level did not account for the socio-communicative difficulties. Implications for our understanding of the socio-communicative abilities of young children with Williams syndrome and diagnostic practices regarding dual diagnosis are discussed.

Does gender influence learning style preferences of first-year medical students?

Students have specific learning style preferences, and these preferences may be different between male and female students. Understanding a student's learning style preference is an important consideration when designing classroom instruction. Therefore, we administered the visual, auditory, reading/writing, kinesthetic (VARK) learning preferences questionnaire to our first-year medical students; 38.8% (97 of 250 students) of the students returned the completed questionnaire. Both male (56.1%) and female (56.7%) students preferred multiple modes of information presentation, and the numbers and types of modality combinations were not significantly different between genders. Although not significantly different, the female student population tended to be more diverse than the male population, encompassing a broader range of sensory modality combinations within their preference profiles. Instructors need to be cognizant of these differences and broaden their range of presentation styles accordingly.

Longitudinal evaluation of fine motor skills in children with leukemia

BACKGROUND

Improved survival for children with acute lymphocytic leukemia (ALL) has allowed investigators to focus on the adverse or side effects of treatment and to develop interventions that promote cure while decreasing the long-term effects of therapy. Although much attention has been given to the significant neurocognitive sequelae that can occur after ALL therapy, limited investigation is found addressing fine motor function in these children and motor function that may contribute to neurocognitive deficits in ALL survivors.

METHODS

Fine motor and sensory-perceptual performances were examined in 82 children with ALL within 6-months of diagnosis and annually for 2 years (year 1 and year 2, respectively) during therapy.

RESULTS

Purdue Pegboard assessments indicated significant slowing of fine motor speed and dexterity for the dominant hand, nondominant hand, and both hands simultaneously for children in this study. Mean Visual-Motor Integration (VMI) scores for children with low-risk and high-risk ALL decreased from the first evaluation to year 1 and again at year 2. Mean VMI scores for children with standard risk ALL increased from the first evaluation to year 1 and then decreased at year 2. Significant positive correlations were found between the Purdue and the VMI at both year 1 and year 2, suggesting that the Pegboard performance consistently predicts the later decline in visual-motor integration. Significant correlations were found between the Purdue Pegboard at baseline and the Performance IQ during year 1, though less consistently during year 2. A similar pattern was also observed between the baseline Pegboard performance and performance on the Coding and Symbol Search subtests during year 1 and year 2.

CONCLUSIONS

In this study, children with ALL experienced significant and persistent visual-motor problems throughout therapy. These problems continued during the first and second years of treatment. These basic processing skills are necessary to the development of higher-level cognitive abilities, including nonverbal intelligence and academic achievement, particularly in arithmetic and written language.

Cognitive characteristics of children with genetic syndromes

This article presents the cognitive profile observed in children with one of several common genetic syndromes associated with "nonverbal learning disorders." It introduces the concept of a cognitive endophenotype to help explain the similar pattern of impairments across the syndromes. It explores the explanation of diverse impairments in higher-order visual, spatial, temporal, numerical, and executive cognitive competencies deriving from origins in more basic attentional and spatial cognitive dysfunctions. The importance of a developmental approach to understanding dysfunction is stressed.

Turner Syndrome

Turner syndrome is a neurogenetic disorder characterized by partial or complete monosomy-X. It is associated with certain physical and medical features, including estrogen deficiency, short stature, and increased risk for several diseases, with cardiac conditions being among the most serious. The cognitive-behavioral phenotype associated with the syndrome includes strengths in verbal domains with impairments in visuospatial, executive function, and emotion processing. Less is known regarding psychosocial and psychiatric functioning in Turner syndrome, but essential aspects of psychotherapeutic treatment plans are suggested. Future investigations should include continued genetic studies and determination of candidate genes for physical and cognitive features. Multimodal, interdisciplinary studies are essential for identifying optimal, syndrome-specific interventions for improving the lives of individuals who have Turner syndrome.

The influence of instruction modality on brain activation in teenagers with nonverbal learning disabilities: two case histories

Teenagers with nonverbal learning disabilities (NLD) have difficulty with fine-motor coordination, which may relate to the novelty of the task or the lack of "self-talk" to mediate action. In this study, we required two teenagers with NLD and two control group teenagers to touch the thumb of each hand firmly and accurately to the fingertips of the same hand, in an order specified by verbal or tactile instruction. Brain activity patterns (measured using functional magnetic resonance imaging) suggest that unlike control participants, the NLD participants used internalized speech to facilitate the novel task only when instructions were verbal. NLD participants also showed activity in a more widely distributed network of neural structures. These findings provide preliminary evidence for remediation strategies that encourage internal speech.